WINDSOR MISSION OAKS has a 2-star overall rating, with weak staffing (2 stars) and quality measures (1 star); reported nurse staffing is 2.70 hours per resident per day, below the 4.1 federal benchmark. It also had $10,842 in fines in the last 24 months and a recent federal penalty, while the health inspection rating was 3 stars.
Last inspection: June 27, 2025Penalties, last 24 months: $10,842recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.7032.
Staffing detail
Registered nurses
0.29
Licensed practical nurses
0.83
Nurse aides
1.58
Weekend nursing
2.14
Hours per resident per day.
Total staff turnover: 24%
Registered nurse turnover: 0%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Last yrNowTrend
Residents with a fall causing major injury
3.9%2.4%Improving
Residents with pressure ulcers (bedsores)
0.9%1.7%Worsening
Residents with a urinary tract infection
0.8%1.6%Worsening
Residents who lost too much weight
2.6%4.5%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
14%11.7%Improving
Residents whose ability to walk got worse
9.7%8%Improving
Long-stay residents on antianxiety or sleep medication
40.2%39.3%Improving
Residents with a long-term catheter
0.9%0%Improving
Residents with new or worsening incontinence
25.5%10.8%Improving
Residents with depressive symptoms
2.7%0%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Last yrNowTrend
Long-stay residents given the seasonal flu vaccine
—99.2%—
Long-stay residents given the pneumonia vaccine
100%99.2%Worsening
Short-stay residents given the pneumonia vaccine
—62.2%—
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2024 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited June 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to provide proper bladder and bowel care, including catheter care and steps to prevent urinary tract infections. Cited June 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 690 — 42 CFR §483.25(e) — S/S: E
The home failed to ensure nurses and nurse aides had the needed skills to care for each resident and support their well-being. Cited June 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 726 — 42 CFR §483.35 — S/S: E
The home failed to properly label and securely store medications and biologicals. Cited June 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — S/S: E
Recent history
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
PENALTY
A federal fine of $10,842 was recorded.
INSPECTION
Health inspection found 13 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $10,842 in total fines.
Federal fine
May 8, 2024
$10,842
Operator & ownership
Ownership
Non profit - Other
Chain
Part of WELLSENTIAL HEALTH · 68 homes · 2.6 stars avg
Occupancy
123.7 residents on an average day (82% of 150 beds)
Resident voice
Resident council
Medicare history
Certified for 31 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.